UTHSCSA Pediatric Resident Curriculum for the PICU
Introduction to the PICU and
Airway Management
The Purpose of Intensive Care
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Units exist to monitor patients for acute
deterioration
Units are staffed by personnel trained to
react to deterioration with advanced skills
Success in management favors the
prepared mind
Keys to Success
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Perform the same approach on every
patient each day
Collect information (exam, notes, labs)
construct a coherent picture, develop an
assessment and formulate a plan
Present in a consistent manner
Predict what problems may develop
Airway Management
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The ability to recognize impending
respiratory failure and stabilize an airway
is one of the cornerstones of ICU
management
Knowledge of the pediatric airway and
proficiency in its stabilization and
intubation is essential
Laryngeal Cartilages
Laryngeal Anatomy (Infant)
Laryngeal Anatomy
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Sensory innervation occurs from the
internal branch of the superior and
recurrent laryngeal nerve, motor
innervation is from the recurrent laryngeal
nerve
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Blood supply is provided by the superior
and inferior thyroid arteries
Four Differences between
the Adult and Pediatric
Airway
• Infant tongue is proportionally large
• The infants larynx is higher (rostral) in the
neck (C3-4) than an adults (C4-5)
• The infants epiglottis is omega shaped ()
and angled away from the trachea
• The narrowest part of the larynx is the cricoid
cartilage below the vocal cords
Larynx Configuration
Adult (cylinder)
Pediatric (funnel)
Airway Diameter and
Resistance
Obstructed
Inspiration/Expiration
Stridor
Wheezing
Work of Breathing
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Product of Compliance and Resistance
Nasal passages account for 25% of airflow
resistance in infants, 60% in adults
Most resistance in infants occurs in the small
airways
– small diameter
– lack of supporting structures
Work of Breathing
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WOB per kilogram body weigh is similar in
adults and children. Higher respiratory
rates are due to greater O2 consumption
– (4-6 ml/kg/min) infants, (2-3 ml/kg/min)
adults
Infant have diaphragm and intercostal
muscles with fewer Type 1 (slow-twitch)
fibers so they are more prone to fatigue
Airway Management
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The Goal of Airway management is to
anticipate and recognize respiratory
problems and to support or replace those
that are compromised or lost
Pediatric Advance Life Support Manual
Important to Remember
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An individual must be able to support
three specific functions:
– Protect their airway
– Adequately ventilate
– Adequately oxygenate
A failure to perform any ONE function will
result in respiratory failure.
Airway Control
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There are many simple, non-invasive
techniques to support respiration prior to
undertaking endotracheal intubation
– Application of oxygen
– Suctioning
– Positioning of the airway
– Application of positive pressure
– Assistance of ventilation with a BVM
Application of Oxygen
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Nasal canula (23-25%)
Simple face mask (35-60%)
Non-rebreather mask (80-100%)
– High flow (10-12 l/min)
– Reservoir of oxygen
– Tight-fitting to face
– Valves to prevent entrainment of room air
Suctioning
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The inability of infants to generate a strong
cough together with their small airways
makes removal of tracheal secretions
important to assure patency
Infants are obligate nasal breathers and
become unruly when their nose is
obstructed. Many an infant was saved from
intubation by a bulb suction!
POSITIONING
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Use of the chin lift and jaw thrust can help
restore flow through an obstructed upper
airway by separating the tongue from
posterior pharyngeal structures.
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The goal is to line up three divergent axes:
oral, pharyngeal and tracheal.
Aligning the Axes (Initial)
Aligning the Axis (Occiput
Roll)
Aligning the Axis (Extension)
Oropharyngeal Airways
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Facilitates relief of upper airway
obstruction due to a large tongue
Allows oropharyngeal suctioning
Prevents compression of a child’s
endotracheal tube due to biting.
Oropharyngeal Tube Selection
Bag-Valve-Mask
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Masks should fit easily over the nose and
mouth with no pressure on the eyes The
base of the mask rests on the chin
Valves allow unidirectional flow of oxygen
to the patient and prevent entrainment of
exhaled waste gas into the system
Bag-Valve-Mask
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There are two types of bags, anesthesia
and self-inflating
Anesthesia bags require a perfectly
closed system to operate and allow finer
control of inspiratory and expiratory
pressures.
Without oxygen flow, the bag will not
inflate.
Anesthesia Bag
Self-Inflating Bag
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Allows rapid ventilation of a patient in an
emergency because it does not need an
oxygen source to operate
Requires the use of a reservoir to deliver
100% oxygen, otherwise it entrains some
room air with the oxygen
Requires a PEEP valve to deliver specific
end-expiratory pressures.
Self-Inflating Bag
Preparation for Endotracheal
Intubation
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Use history and physical exam to predict
a difficult airway
Exam clues to the difficult airway
– Mouth opening test
– Loose teeth
– Mandible space (genu to thyroid
cartilage)
– Presence of congenital abnormalities
Preparation for Endotracheal
Intubation
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Gather all necessities
– Needed personnel
– Appropriate endotracheal tubes
– Appropriate laryngoscope blades
– Airway adjuncts ( stylets, oral airways etc.)
– Suctioning equipment
– BVM attached to oxygen at proper flow
– Medications
Miller Vs Macintosh
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Miller (straight) blades are used to lift the
epiglottis & expose the vocal cords
– usually used in infants and small
children
Macintosh (curved) blades are placed into
the vallecula lifting the base of the tongue
which in turn lifts the epiglottis.
– Used primarily in older children and
adults
Miller and Macintosh
Placement
Procedure for intubation
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Successful intubation involves a series of 6 separate
maneuvers.
– proper sedation (when required)
– proper positioning (align the axis)
– establishing a patent airway (BVM)
– sweeping the tongue
– visualization of the airway/cords
– placement of the endotracheal tube
Anatomic Landmarks
Intubation faux pas
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“Shoulder rolls” in children 2 or older
Laryngoscopes held in the right hand
Using the teeth as a fulcrum (tooth fairy)
Passing the endotracheal tube down the
barrel of the laryngoscope
Neck extension when spinal cord injury is
suspected
Early release of cricoid pressure
Post-intubation considerations
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Bilateral breath sounds before tube
secured and chest x-ray ordered
NGT in place for gastric decompression
Tube migration into right mainstem or
esophagus
Suctioning the tube following placement
Ventilator settings provided
Special Situations
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Trauma patient in a C-collar
Downs, Pierre-Robin and why can’t I see
the vocal cords
Pulmonary Edema
Laryngospasm
Full Stomach